<?php 
$query =mysql_query("select * FROM country");
?>
<form name="create_campaign" method="POST" id="create_campaign" action=""  enctype="multipart/form-data">
<link href="campaign/images/style-master.css" rel="stylesheet" type="text/css">
<script type="text/javascript" src="campaign/images/add-credit-card.js"></script>

<div class="general-content-area">
	<div class="page-header" style="width:100%;">
		<div style="float:left;width:100%;"><h1>Enter Credit Card Information</h1></div>
	</div>
	<div id="content-area" style="width:100%;">
		<div style="float:left;width:100%;"><?php if(!empty($message)) { echo $message;} ?></div>
			<div class="form-box" style="margin: 0pt;">
				<h3 align="left">Credit card info</h3>
				<span class="label required">Card type*:</span> 
				<span class="form-subbox"> 
					<select name="card_type" style="margin-left:0px;width:200px;">
						<option value="Visa">Visa</option>
						<option value="Discover">Discover</option>
						<option value="MasterCard">MasterCard</option>
						<option value="American Express">American Express</option>
					</select> 
				</span><br>
				<div style="margin: 5px 0px; text-align: right;"><img src="campaign/images/credit_cards.gif" alt="credit card" style="border: medium none; padding: 5px; background: rgb(255, 255, 255) none repeat scroll 0% 0%; margin-left: 10px; vertical-align: middle; -moz-background-clip: -moz-initial; -moz-background-origin: -moz-initial; -moz-background-inline-policy: -moz-initial; margin-right: 30px;" width="160"></div>
				<span class="label required">Credit card number*:</span> 
				<input id="card-number" name="card_number" value="" type="text" style="width:200px;margin-left:0px;"><br>
				<span class="label required">Expiration date*:</span>
				<span class="form-subbox"> 
					<select name="card_exp_month" class="expiration-date" style="margin-left:0px;">
						<option value="01">01 - January</option>
						<option value="02">02 - February</option>
						<option value="03">03 - March</option>
						<option value="04">04 - April</option>
						<option value="05">05 - May</option>
						<option value="06">06 - June</option>
						<option value="07">07 - July</option>
						<option value="08">08 - August</option>
						<option value="09">09 - September</option>
						<option value="10">10 - October</option>
						<option value="11">11 - November</option>
						<option value="12">12 - December</option>
					</select> 
					<select name="card_exp_year" class="expiration-date" style="margin-left:5px;">
						<option value="2007">2007</option>
						<option value="2008">2008</option>
						<option value="2009">2009</option>
						<option value="2010">2010</option>
						<option value="2011">2011</option>
						<option value="2012">2012</option>
						<option value="2013">2013</option>
						<option value="2014">2014</option>
						<option value="2015">2015</option>
						<option value="2016">2016</option>
						<option value="2017">2017</option>
					</select> 
				</span> <br>
				<span id="cvn" >
					<span class="label required">CVN*:</span> 
					<div style="text-align: left;">&nbsp;<input id="cnv" name="cvn" value="" type="text" >&nbsp;&nbsp;[&nbsp;<a href="#" onclick="window.open('cvv2_desc.html','cvv2','width=500,height=600,toolbar=no,location=no,directories=no,status=no,menubar=no,scrollbars=yes,copyhistory=no,resizable=yes');return false"> what is this?</a> ]</div>
				</span>
					<h3 align="left">Billing address</h3>
					<span class="label">&nbsp;</span>
					<input id="use-account-address" name="use-account-address" style="margin-left:-44px;" onclick=" if(document.getElementById('use-account-address').checked)useAccount();" type="checkbox"> <span class="form-text">Same as "account info"</span>
					<br>
					<span class="label required">Name*:</span> 
					<input id="billing-name" name="billing_name" value="" type="text" style="width:200px;margin-left: 0px;"><br>
					<span class="label required">Address*:</span> 
					<input id="billing-address" name="billing_address" value="" type="text"  style="width:200px;margin-left: 0px;"><br>
					<span class="label required">City*:</span> 
					<input id="billing-city" name="billing_city" value="" type="text"  style="width:200px;margin-left: 0px;"><br>
					<span class="label required">State*:</span> 
					<input id="billing-state" name="billing_state" value="" type="text"  style="width:200px;margin-left: 0px;"><br>
					<span class="label required">Zip or postal code*:</span>
					<input id="billing-zip" name="billing_zip" value="" type="text"  style="width:200px;margin-left: 0px;"><br>
					<span class="label">&nbsp;</span><small>(Required for US and Canada only)</small><br>
					<span class="label required">Country*:</span>
					<span class="form-subbox">
						<select id="select" name="billing_country" style="width:200px;margin-left: 0px;">
							<?php 
								while($result = mysql_fetch_array($query))
								{
									echo "<option value='".$result['countries_iso_code_2']."'>".$result['countryName']."</option>";
								}
							?>
						</select>
					</span>
			</div>
			<div style="clear: both;"></div>
			<div style="padding-top:20px;">
			<input value="step4" id="next-btn" type="hidden" name="mode">
			<input value="Update card" id="next-btn" type="submit" name="submit"></div>
	
		
	</div>	
</div>
</form>
